Skip to Content

Human Resources Department

Liability & Insurance

Sample Form 13: Additional Insured – Permits or Authorizations

Liability & Insurance 750

State or Governmental Agency or Subdivision or Political Subdivision - Must show the name of the additional insured or "by contract". Not acceptable if left blank.
Section II - Who is An Insured -

We are protected only if we issued a permit or other authorization.

We are not protected if the permittee is doing work FOR us. For that we need Sample Form 4 & 5.